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Post-operative pain and pain management in children after dental extractions under general anaesthesia.

Introduction

Despite improved dental health in Swedish children during the last decades, some still have such extensive treatment need that dental rehabilitation under general anaesthesia (GA) is indicated. One study found that pre-school children who were treated under GA because of caries had up to 12 teeth (mean 5) extracted [Twetman et al., 1999]. Another condition where GA is often the considered mode of treatment is severe idiopathic enamel hypo-mineralisation of first permanent molars (FPMs), which occurs in approximately 7% in child populations [Jalevik et al., 2001]. Extensive disintegration of these teeth often causes pain and requires repeated fillings, and extraction minimises future needs for restorative treatment.

Many children with untreated carious lesions may have had to learn to cope with pain and discomfort in the mouth during eating and tooth brushing [Easton et al., 2008]. Children with a history of pulpal symptoms also run a greater risk of dental anxiety and behavioural problems [Jalevik and Klingberg, 2002]. When treatment is performed, it is important that a child's GA experience is as comfortable as possible. Follow-ups show that in the first days after GA treatment, over half of the children, according to their parents, have more pain than usual in the mouth, and over a third experience moderate pain or worse [Atan et al., 2004; Hosey et al., 2006]. Within 2 weeks post-operatively, however, parents judge their child's quality of life to be significantly improved concerning pain, eating and sleeping [Acs et al., 2001; Anderson et al., 2004].

Pain in children can be difficult to recognise. Small children may lack the cognitive ability and vocabulary to express their distress. When pain is recurrent, some children develop coping skills to deal with the pain, and this may be misleading. During medical procedures, many children do not spontaneously report pain. After discharge from an emergency department, for example, quiet and subdued behaviour was more prevalent than complaints and distinct signs of pain [Zisk et al., 2007a]. Several studies show that health professionals and parents have a tendency to underrate pain and distress in children [Solomon, 2001; Singer et al., 2002].

Because post-operative pain tends to be overlooked, and the effect of analgesics overrated, it is not uncommon for children to be given less medication than was prescribed [Finley et al., 1996; Gauthier et al., 1998; Rony et al., 2010]. For adequate pain management, the most accurate information is obtained by asking the child, when possible, and preferably with the use of self-reported measures. Even when pain is recognised, many parents under-medicate, perhaps because of uncertainty about the utility of analgesics and fear of potential side-effects [Rony et al., 2010].

The aim of the present study was to evaluate post-operative pain after dental extractions under GA and to compare children's self-ratings of pain with those of a parent. Use of analgesics in the post-operative period was also studied.

Materials and methods

All consecutive healthy children aged 3-12 years who were referred from January 2004 to April 2009 because of extensive treatment needs and/or dental fear, to three clinics of Specialised Paediatric Dentistry in the western part of Sweden for comprehensive dental care with extractions under GA, were included in the study. Fluency in Swedish, for both child and parent, was an inclusion criterion. All parents signed informed consent forms, and each child consented verbally, when possible. The local Ethics Committee at the University of Gothenburg approved the study.

Treatment took place at one of five hospitals. During GA, all children received local analgesia before dental extractions. Analgesics were administered as suppositories according to hospital routines. After treatment, each child and one parent responded to questionnaires on five occasions: in the post-operative ward before discharge and the evening of the treatment day (day 1) and in the following three evenings (days 2-4). Parents rated their child's pain intensity on a 10-centimeter visual analogue scale (VAS) first. Children then made two ratings, one on a facial analogue scale (FAS) [Wong and Baker, 1988] and one on a coloured analogue scale (CAS) [McGrath et al., 1996] (Figure 1). The endpoints on the scales were 0 for "no pain" and 10 for "worst possible pain". Verbal and written instructions regarding the pain scales and pain management at home had been provided prior to the GA.

[FIGURE 1 OMITTED]

For pain treatment at home, analgesics were recommended as a standard medication 3-4 times a day. Paracetamol, 15 mg [kg.sup.-1], was recommended for all patients for at least 2 days, and after extractions of permanent teeth or in case of severe pain, ibuprofen[R], 5 mg [kg.sup.-1], was recommended for at least 3 days. The parents recorded the daily intake of analgesics in the questionnaire, and whether their child had complained of pain.

Statistical analysis

Spearman's rank correlation coefficient was used to make pair-wise comparisons between the parental rating (VAS) and each of the child's ratings (FAS and CAS), and between each child's two ratings. A power analysis determined that to detect a minimal relevant difference between groups at a 95% confidence level, with an error margin of 0.07 and a correlation coefficient (rho) of around 0.8, a sample size of 100 would be needed. All data was processed in the Statistical Package for the Social Sciences (SPSS, version 19, SPSS Inc, Chicago, IL USA), and a significance level of 5% was used in all tests.

The actual values of the pain scale ratings were used in all statistical analyses. In the text and figures, the ratings were classified as "no pain" (0), "mild pain" (0.1-2.0), "moderate pain" (2.1-4.0), "severe pain" (4.1-6.0), "very severe pain" (6.1-8.0) and "worst possible pain" (8.1-10) (Figure 1).

Results

131 consecutive eligible patients were invited to participate. The parent of one child declined; 30 parents failed to return the questionnaire despite being reminded by telephone. Of the 100 children who participated in the study, 51 were boys and 49 were girls (median age 5.8 years, range 2.8-12.8).

Only primary teeth were extracted in 78 patients, both primary and permanent teeth in 8 patients, and only permanent teeth in 14 patients. The median number of extracted primary teeth was 5 (range 1-12), and of extracted permanent teeth 3 (range 1-4). Of the permanent teeth, all but 2 were FPMs.

All children received intra-operative analgesics. In 89% paracetamol was administered, in 47% NSAID and in 36% opioids and 60% received a combination.

Pain assessment. The highest pain ratings on the VAS, FAS and CAS were made in the post-operative ward before discharge, where 35%, 39% and 39%, respectively, rated the pain as "moderate" or higher while six patients rated the pain as "worst possible" on the FAS and five on the CAS (Figure 2). There was no indication that differences in intra-operative analgesics affected the pain rating.

[FIGURE 2 OMITTED]

On the evening of the day of treatment, 74%, 74% and 70% rated the pain on the VAS, FAS and CAS, respectively, as "no" or "mild pain" while one patient rated the pain as "worst possible" on the CAS (Figure 3). On the following day (day 2) 77%, 73%, 70% rated the pain as "no" or "mild pain" on the VAS, FAS and CAS, respectively, while two patients rated their pain as "worst possible" on the FAS and CAS (Figure 4).

On day 3, 90%, 89% and 83%, respectively, rated the pain as "no" or "mild pain" while one patient rated the pain as "worst possible" on the FAS, and two on the CAS (Figure 5). On day 4, 95%, 94% and 89%, rated the pain on the VAS, FAS and CAS, respectively, as "no" or "mild pain" while one patient rated the pain as "severe" on the FAS (Figure 6). The maximum values of pain were high on all days, but median values never exceeded 1.0, 2 and 1.4 on the VAS, FAS and CAS, respectively, indicating "mild pain" that decreased over time (Table 1). There was no indication that the number of extracted teeth, or whether they were primary or permanent teeth, had any influence on pain intensity.

Comparison of pain ratings. All correlations, both between ratings by the parent and child (VAS-FAS and VAS-CAS) as well as between the two ratings made by the child (FAS-CAS), were significant with p-values less than 0.01. The correlation coefficient rho varied between 0.63 and 0.90 (Table 2). Some discrepancies did occur. One child rated the pain as "worst possible" on both scales while the parent rated it as "mild". Four children rated their pain two levels higher in pain intensity than their parents on one occasion, and one parent rated the child's pain two levels higher than the child. In all other cases, ratings were closer.

[FIGURE 3 OMITTED]

[FIGURE 4 OMITTED]

[FIGURE 5 OMITTED]

[FIGURE 6 OMITTED]

Analgesic consumption. Medication after discharge from the hospital was most prevalent on the day of treatment when 60 parents administered analgesics to their children (Table 3). On day 2, of the 45 children who consumed analgesics, 12 received 2 doses, 8 received 3 doses, and 9 received 4 doses. 33 children who received no medication after leaving the hospital.

The number of days that the children received analgesics was 1 day for 22 children, 2 days for 20 children, 3 days for 9 children, and 4 days for 16 children. One child refused medication on day 2; 18 children received a combination of paracetamol and ibuprofen; the proportion of children who had primary teeth extracted and received this combination of analgesics was the same as for those who had permanent teeth extracted. The remaining children received paracetamol or, in two cases, ibuprofen. There was no indication of a connection between the number of extracted teeth and the administration of prescribed medication.

Discussion

This study was undertaken to evaluate pain after multiple dental extractions performed under GA. The results indicate that the majority of children have low levels of pain despite multiple extractions. However, a few children reported high pain intensity occasionally, on all post-operative days. Validated scales were used and the concordance in the pain assessments between parent and child was high. Adherence with recommendations for pain management was poor, and a third of the patients received no analgesics after discharge.

Pain assessment. The highest pain ratings occurred in the post-operative ward, with up to 40% rating their pain as "moderate" or higher. All children had local analgesia, which has been associated with feelings of dizziness and negative symptoms in the first post-operative hours [Atan et al., 2004; Townsend et al., 2009]. One study did not find the use of local anaesthesia to reduce pain scores after multiple dental extractions in children compared to a placebo [Coulthard et al., 2006]. In the present study, few of the children had previous experience of local analgesia, and numbness, together with symptoms related to the GA, may have increased their distress and experience of pain in the post-operative ward.

The median scores of all pain assessments were rather low and never exceeded 2 out of 10, indicating "mild" pain, but the maximum values were high, especially on the FAS with a value of 10 even on day 3 in one child. One study reported that 9% had strong or severe pain 36 hours after surgery, which is comparable to "severe pain" or higher on day 2 in the present study [Atan et al., 2004]. Between 8 to 11% of children gave ratings at this level on the three scales in this study.

Seven children rated the pain as "very severe" or "worst possible" from day 2 onwards. One child experienced high pain intensity that persisted throughout the study period. Otherwise, the children who rated their pain intensity as "very severe" or "worst possible" varied between assessments. It has been suggested that age and extraction of primary rather than permanent teeth may influence the pain experience [Fung et al., 1993]. This study found no indication that either age, number of teeth, or gender was important.

Fifty-five children reported "no" or "mild pain" on all assessments after discharge. 25 of these received no analgesics, including one who had 12 primary teeth extracted and another who had had all FPMs extracted. It is not unusual for children to experience pain while waiting for the GA session [North et al., 2007]. Regarding their dental status, many children in the present study possibly had a long-standing history of oral pain episodes, not always attended to, and might have acquired coping skills to minimise their pain.

Comparison of pain ratings. The ratings of pain between parent and child were highly concordant. When parents try to identify pain in a child, they often use specific behavioural cues. Self-report measures are considered to be the most valid method of assessing pain in children, but parental global impressions can be a good adjunct in identifying both those who are in pain, and those who are not [Zisk et al., 2007a]. It has also been suggested that the parental perception of children's pain should only be considered as estimates, as the correlation is moderate [Zhou et al., 2008]. In the present study, parents rated the pain first so as not to be biased by the child. Since the child was not blinded to the parental assessment, an unconscious influence might have existed, but the use of different scales possibly reduced this risk. It is not uncommon that parents tend to underestimate when a child is experiencing clinically significant pain [Chambers et al., 1998]. The findings in the present study do not wholly support this, but this did occur in one case where the child rated the pain as "worst possible" and the parent rated the pain as "mild". For five children, the discrepancy was two levels out of five in pain intensity, on one occasion each. All other pain ratings were closer.

Analgesic consumption. The recommendation to take analgesics at appointed times was poorly followed, and 33% of the children received no medication after discharge. On day 2, the first full day at home, only 29% had more than one dose. A previous study showed that misconceptions regarding the benefit of analgesics and fear of adverse effects are common, and many parents are reluctant to medicate their children [Rony et al., 2010]. They found that only 35% prescribed the recommended number of doses after elective outpatient surgery, which is in line with the present study.

All patients with extractions of permanent teeth had FPMs extracted. As ibuprofen[R] has been shown to be superior compared to paracetamol alone [Gazal and Mackie, 2007], parents were advised to administer both drugs. This recommendation was only followed in 23% of the children with extractions of permanent teeth. Some parents failed in the management of pain, even when significant pain was recognised. Twelve children rated their pain as "very severe" to "worst possible" at one of the four assessments after discharge, and one of these received no medication at all. Parental tendency to underestimate even clinically significant pain has been shown previously, with under-dosing of analgesics despite high ratings of post-operative pain [Chambers et al., 1998; Fortier et al., 2009]. The use of self-reported pain scales has not been shown to improve pain management at home [Unsworth et al., 2007], which the present study supports.

On day 2, up to 40% of the children complained about pain, evidence that pain management was inadequate. Most of the children who complained received analgesics, but one child received no medication after day 1, despite complaints and pain values indicating "moderate" to "severe pain" throughout the study period. Withholding medication is hard to understand, but it has been suggested that some parents might believe that analgesics should be used only as a last resort [Rony et al., 2010]. There are also indications that less educated parents are more likely to avoid giving analgesics [Zisk et al., 2007b]. An association between low education and early childhood caries was previously shown [Grindefjord et al., 1996]. It can be assumed that many parents in the present study had a low education level, but this was not investigated further.

Many children reported low levels of pain, even without administration of the prescribed analgesics, which was a surprising finding. Thirty-three children consumed no analgesics after discharge on day 1, and the highest pain assessment of 25 of these children was "mild pain". One of these 25 children had 12 primary teeth extracted and another child had all four FPMs extracted. These low pain ratings might have several explanations. Child characteristics and anticipation may influence pain perception with some children being naturally more tolerant and better able to cope. Many children showed no indication of dental anxiety, a condition found to enhance post-operative symptoms [Hosey et al., 2006]. The parents might also have used distraction or other behavioural interventions to modify the pain experience to some extent. Nevertheless, appropriate administration of analgesics is fundamental in all pain management and these children need the best comfort and support they can get.

Pain management recommendations were mainly given to the parents on the day of the GA. The results indicated that pain management was often sub-optimal, and it might be better to discuss pain treatment at an earlier stage. More time for discussion of analgesic use might influence parental attitudes and improve pain management. A previous study found that one-quarter of parents were of the opinion that medication works best "if saved for when pain is quite bad" and when "given as little as possible" [Rony et al., 2010]. More attempts at discussion with parents might motivate better pain management and increase the chance that they administer the prescribed medication.

Conclusion

Most children reported only mild post-operative pain after discharge from hospital. Although parents seem accurate in their assessment of pain, administration of analgesics is inadequate. Interventions aimed at improving appropriate pain management practices need to be developed.

Acknowledgements

This study was supported by grants from The Mayflower Charity Foundation for Children [Majblomman]. Staffs at the Public Dental Service specialist clinics in paediatric dentistry in Boras, Halmstad and Gothenburg are gratefully acknowledged for help with clinical treatment.

References

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B. Jensen

Dept of Paediatric Dentistry, Public Dental Service, Region Vastra Gotaland, Sweden

Postal address: Dr B. Jensen, Public Dental Service, Region Vastra Gotaland, Dept of Paediatric Dentistry, Box 7163, SE-402 33 Gothenburg, Sweden.

Email: boel.jensen@vgregion.se
Table 1: Median and maximum pain ratings over time.
Parental rating on the visual analogue scale (VAS)
and children's self-ratings on the facial analogue
scale (FAS) and the coloured analogue scale (CAS).

          Post-op   Evening   Evening   Evening   Evening
           ward      day 1     day 2     day 3     day 4

VAS
median      1.0       0.4       0.3       0.2       0.1
maximum     9.2        8        9.1       7.8       5.7

FAS
median       2         2         2         0         0
maximum     10         8        10        10         8

CAS
median      1.4       0.5       0.4       0.2       0.1
maximum     10        8.6       9.1       8.3       5.3

Table 2: Correlation coefficients, Spearman's
rho, for pair-wise pain ratings. Parental rating
on the visual analogue scale (VAS) and children's
self-ratings on the facial analogue scale (FAS)
and the coloured analogue scale (CAS). All
correlations with p-values <0.01.

                VAS-FAS   VAS-CAS   FAS-CAS

Post-op ward     0.78      0.81      0.90
Evening day 1    0.78      0.86      0.87
Evening day 2    0.81      0.85      0.86
Evening day 3    0.72      0.78      0.80
Evening day 4    0.63      0.84      0.75

Table 3: Number of children who used analgesics
and number of children who complained about
pain in the post-operative period
(n=100).

             Treatment   Day 2   Day 3   Day 4
                day

Use of          60        45      29      20
analgesics

Analgesics      19        29      19      10
>1 dose

Complained      36        40      22      18
about pain
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Author:Jensen, B.
Publication:European Archives of Paediatric Dentistry
Article Type:Report
Geographic Code:4EUSW
Date:Jun 1, 2012
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